Author: Rachael Graham RCP, CRT, RPSGT
Corporate Surveyor

On February 1, 2025, ACHC released revisions and updates to standards for Sleep Accreditation that become effective June 1, 2025. Most of these updates clarify existing standard requirements. However, two specific additions introduce requirements that may necessitate changes in sleep lab equipment and processes:

• Standard 5-1A: Updated to require that video recordings be stored as part of the patient record.
• Standard 7-6A: Updated to require that all sleep rooms have video recording capabilities.

While many facilities already meet these requirements, some may need to make adjustments to ensure continuing full compliance with Sleep Accreditation standards.

Intent of the changes

The decision to implement these updates is rooted in two key priorities:

• Enhancing Patient and Personnel Safety
  Video recordings provide an added layer of security for both patients and healthcare personnel. The ability to review footage can help identify potential concerns, address patient complaints, and ensure that proper procedures are followed during sleep studies.
• Compliance with HIPAA and PHI Regulations
  Video recordings that capture patient interactions or clinical procedures are considered Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA). As PHI, patient consent is required and must be documented.

Best Practices for Maintaining Video Recordings

ACHC does not dictate a specific method for storing and backing up video recordings. Facilities have several options for PHI storage, including maintaining video recordings:

• Cloud-based storage solutions offer scalable, secure PHI storage solutions that provide remote access when needed. Ensure that any you consider are HIPAA-compliant.
• External hard drives allow facilities to manage their own data without relying on third-party cloud services.
• CDs/DVDs or other physical media can be cost-effective but will require proper cataloging and security measures to prevent data loss or breaches.

Regardless of the storage method chosen, facilities must take necessary precautions to ensure that recordings are securely maintained as part of the patient record, compliant with HIPAA regulations, encrypted (if stored digitally), accessible only to authorized personnel, and capable of long-term retention if necessary.

Your Compliance Timeline

Our new standard requirements will officially take effect on June 1, 2025. From this date forward, all ACHC-accredited sleep facilities must fully implement these requirements.

Any customer surveyed after June 1, 2025 who does not meet the updated standard requirements, will receive a deficiency finding. Non-compliant facilities will be provided with sufficient time to make necessary adjustments and meet the updated Sleep Accreditation standards. To avoid a flurry of corrections postsurvey, we strongly recommended that you take proactive measures to ensure compliance before the effective date.

To ensure a smooth transition before the June 1, 2025 deadline, take the following steps:

1. Assess Current Capabilities: Review your current procedures to determine if your facility already meets the updated standards or if modifications are needed. If your process needs to be revised, make those policy and procedure changes and schedule staff training prior to the effective date.
2. Evaluate Storage Solutions: Select a HIPAA-compliant method for storing video recordings as part of the patient record.
3. Train Staff: Educate personnel on the importance of video recording in sleep studies, proper handling of recorded data, and HIPAA compliance requirements.